CASE REPORT

Neutral Zone approach for severely atrophic ridges;

Avenues beyond implants and surgeries A Case Report
Chandni Jain,1 Roshni Goel,2 Prince Kumar, 3 Harkanwal Preet Singh, 4

ABOUT THE AUTHORS

1. Dr. Chandni Jain MDS

Private Practitioner
Jabalpur- 482002, Madhya
Pradesh, India
2. Dr. Roshni Goel
PostGraduate Student
Institute of dental studies
and technology
Modinagar-201201, Uttar
Pradesh, India
3. Dr. Prince Kumar
PostGraduate Student
ITS Dental College,
Ghaziabad- 201206, Uttar
Pradesh. India.
4. Dr. Harkanwal Preet
Singh
PostGraduate Student
ITS Dental College,
Ghaziabad- 201206, Uttar
Pradesh. India.

Corresponding Author:
Dr. Chandni Jain MDS
Private Practitioner
Jabalpur- 482002, Madhya
Pradesh, India
Email.:
poojagupta20032007@gmail.com

Abstract
One of the most common problems encountered among long term denture wearers is the
reduction in the denture foundation. Prosthodontic Rehabilitation of a patient with severely
resorbed ridge is the most challenging therapy a prosthodontist can undertake. In order to
have a favourable prognosis for the denture therapy, impression technique selected should be
based on the present state of the basal tissue support. This article presents the application of
neutral zone (NZ) concept being incorporated in to impression making procedure in an effort
to achieve successful complete denture therapy.

KEYWORDS: Neutral zone, Dead zone, Atrophic mandible, Impression, Index.

Introduction
During childhood teeth erupt under the influence of muscular environment created by
forces exerted by tongue cheeks and lips, in addition to the genetic factors. These
forces has a definitive influence upon the position of the resultant arch form, and the
occlusion. Generally muscular activity and habits which develop during childhood
continue throughout life and after the loss of the teeth, it is important that the artificial
teeth be placed in the arch form compatible with the muscular forces.
As the area of the impression surface decreases (due to alveolar ridge resorption), less
influence it has on the denture retention and stability. Consequently, retention and
stability becomes more dependent on correct positioning of the teeth and the
contours of the external or polished surface of the dentures. Therefore these surfaces
should be so contoured that horizontally directed forces applied by the peri-denture
muscles should act to seat the denture in this well balanced muscular space. This
potential space is known as neutral zone or, which is bounded by the tongue medially,
and the lips and cheeks laterally.
The success of any prosthesis depends on the proper position of the artificial teeth
1
within the neutral zone. Weinberg stated that buccal cusps and fossae of the
2
posterior teeth should be directly over the crest of the ridge. Heartwell and Rahn
indicated that the posterior teeth should be positioned buccolingually on the residual
3
alveolar ridge. Pound stated that invariably arranging the teeth over the crest of the
residual ridge condemned patients by accentuating facial deformity, provoking
phonetic problems and making food manipulation difficult during deglutition.
4
5
6
7
Robinson , Payne , Murray , and Watt are of the opinion that artificial teeth should be
8
positioned where the natural teeth grew. Beresin and Schiesser have suggested that
the denture teeth should be arranged in the neutral zone, where during function the
forces of the tongue pressing outward are neutralized by the forces of cheek and lips
pressing inward. Failure to recognize the importance of tooth position, flange form
6
IJCDS
and contour
AUGUST,
often
2011results
2(3) in2011
dentures
Int. Journalwhich
of Clinical Dental
are unstable
Science
and unsatisfactory.

pressing inward. Failure to recognize the importance of

tooth position, flange form and contour often results in
dentures which are unstable and unsatisfactory.
Dental implants placed with neutral zone technique
stabilize the denture fabricated over atrophic mandibular
ridge. However, there may be certain medical, surgical or
economical conditions when it is not possible to provide
implants. In such complex cases the neutral zone
impression technique is the only option left for the
stabilization of the complete denture. It is not only a
treatment of choice in atrophic mandible but also in
patients with partial glossectomy, mandibular resections
or motor nerve damage to the tongue which have led to
either atypical movement or an unfavourable denture
bearing area. This present article describes the
fabrication of a complete denture using neutral zone
impression technique for enhanced stability and
masticatory efficiency.

the water bath and was carried into the patients mouth.
With the record base firmly seated, the patient was
asked to perform a series of actions like swallowing,
speaking, sucking, pursing lips, pronouncing vowels
sipping water and slightly protruding the tongue several
times which simulated physiological functioning.

Case Report
A 71 year old male patient reported with the complaint
of missing teeth and wanted its artificial replacement. On
examination, it was found that both the upper and the
lower arches were edentulous and severely resorbed
(fig.1).
Figure. 2 Establishing neutral zone using impression
compound
During function of the lips, cheeks, and the tongue, the
forces exerted on the soft compound molds it into the
shape of the neutral zone. After a few minutes when the
compound has cooled, the record base with the
compound rim (fig.2) is removed and placed in cool
water bath. Maxillary rim was oriented in the patients
mouth, the height of the lower compound rim was
adjusted with a sharp knife and Jaw registration was
carried out.
Figure.1 Edentulous Maxilla & Mandible
The wash impressions were made in a custom tray with
zinc oxide eugenol impression material (Dental Products
of India Ltd, India). During recording of the secondary
impression the patient was asked to open, swallow and
speak so as to bring all the muscles into function. The
obtained impressions were poured with dental stone.
The record bases were fabricated, assessed and modified
for stability, extension and comfort. Before making the
neutral zone impression, the patient was made
comfortable in an upright position with the head
supported. The impression material (Green Impression
0
Compound; Kerr Corp) was softened in a 65 C water
bath. The softened compound was kneeled and a roll
was formed according to the crest and was attached to
the base. The attached roll of compound was reheated in
7

IJCDS AUGUST, 2011 2(3) 2011

The neutral zone impression so obtained was placed on

the master model, locating grooves were cut on the
master cast and was covered with a silicone putty index
around the impression on both the labial and lingual
sides (fig.3).

Figure. 3 Making tounge, lip and cheek matrices using

silicone putty
Int. Journal of Clinical Dental Science

The compound occlusal rim was then removed from the

base plate and the index is replaced. The index would
have preserved the space of the neutral zone. Teeth
arrangement was done exactly following the index (fig.4).
The position of the teeth was checked by placing the
index together around the wax try-in. Once the waxed
up trial dentures were ready, they were checked in the
patients mouth for aesthetics, phonetics and occlusion.

Figure. 6 Processing the dentures

Figure. 4 Selecting and arranging teeth in accordance to

putty index
Later on, wax was removed from the labial and the
lingual surfaces of the trial dentures leaving only minimal
wax which could support the teeth that were placed.
Patient was trained for making physiological movements
such as tongue, cheek and lip movements. Once the
patient was trained regarding the functional movements
PVS light body (Aquasil Ultra LV Fast Set; Dentsply Caulk)
was placed on the labial as well as lingual surfaces of the
trial dentures (fig.5), it was placed in the mouth and
patient was asked to perform movements. This
procedure was carried out for both the maxillary and
mandibular arches.

Figure. 5 Obtaining impression of the polished surface

and establishing their contours in wax-up

Figure. 7 Postoperative view of patient

This recorded the polished surfaces of the denture
according to the neutral zone (fig.5). Once the try-in was
deemed satisfactory the dentures were processed and
finished (fig.6). Care was taken during finishing and
polishing of the dentures so that the contours recorded
previously were unaltered. During insertion the dentures
are fully checked to eliminate any minor errors. The
dentures provided the patient with improved facial
appearance, stability and retention during function as
they have been constructed in harmony with their
surroundings (fig.7).
Discussion
The ultimate goal of any prosthodontic treatment is to
restore the form, function, and esthetics of the patient.
9
Fish pointed that out of the three surfaces of the
denture the polished surface is bounded by the tongue
and the cheeks. These are involved in normal physiologic
movements such as speech, mastication, swallowing,
smiling, and laughing. Hence, the fabrication of the
denture must be in harmony with these functions.
Because physiologically unacceptable denture is
10
responsible for poor prosthesis stability and retention ,
11
12
insufficient facial tissue support , less tongue space
11
and compromised phonetics . Denture fabricated over

IJCDS AUGUST, 2011 2(3) 2011 Int. Journal of Clinical Dental Science

a severely resorbed mandibular ridge by neutral zone

impression technique will insure that the muscular forces
aid in the retention and stabilization of the denture
13,14
rather than dislodging the denture during function
.
The dentures will also have other advantages such as
reduced food lodgment, good esthetics due to facial
support, proper positioning of the posterior teeth which
15
allows sufficient tongue space . Clinicians must identify
and record the neuromuscular dynamics of the oral
tissues and this should be applied in the construction of
the definitive prosthesis that will exist within the
stabilizing boundary conditions of the neutral zone area.
Conclusion
With advancement in dental material science and
development of newer techniques in prosthodontics, the
neutral zone impression technique may be incorporated
into fabrication of any complete denture. Though this is
indicated for patients with severe residual ridge
resorption, the procedures discussed can also be used
for full mouth rehabilitation of edentulous patients with
dental implants.

2.
3.

5.
6.
7.
8.
9.
10.
11.
12.
13.

References
1.

4.

Weinberg L. Tooth position in relation to the

denture base foundation. The Journal of
Prosthetic Dentistry. 1958;8(3):398-405.
Heartwell C, Rahn A. Syllabus of complete
dentures: Lea & Febiger; 1974.
Pound E. Lost fine arts in the fallacy of the
ridges. The Journal of Prosthetic Dentistry.
1954;4(1):6-16.

14.
15.

Robinson S. Physiological placement of artificial

anterior teeth. Journal of the Canadian Dental
Association. 1969;35(5):260.
Payne A. Factors influencing the position of
artificial upper anterior teeth. The Journal of
Prosthetic Dentistry. 1971;26(1):26-32.
Murray C. Re-establishing natural tooth position
in the endentulous environment. Australian
Dental Journal. 1978;23(5):415.
Watt DM. Tooth positions on complete dentures.
J Dent. 1978;6(2):147-60.
Beresin VE, Schiesser FJ. The neutral zone in
complete
dentures.
J
Prosthet
Dent.
1976;36(4):356-67.
EW. F. An analysis of the stabilizing force in full
denture construction.Br Dent J. 1947;83:137-42.
Wright CR. Evaluation of the factors necessary to
develop stability in mandibular dentures. J
Prosthet Dent. 1966;16(3):414-30.
Fahmy FM, Kharat DU. A study of the importance
of the neutral zone in complete dentures. J
Prosthet Dent. 1990;64(4):459-62.
Wright C, Swartz W, Godwin W. Mandibular
denture stability: a new concept: Overbeck; 1961.
Fahmi F. The position of the neutral zone in
relation to the alveolar ridge. The Journal of
Prosthetic Dentistry. 1992;67(6):805-9.
Lammie GA. Aging changes in the complete
lower denture. J Prosthet Dent 1956;6:450-64.
Lott F, Levin B. Flange technique, an anatomic
and physiologic approach to increased retention,
function, comfort, and appearance of denture. J
Prosthet Dent 1996;16:394-413.

IJCDS AUGUST, 2011 2(3) 2011 Int. Journal of Clinical Dental Science